Frequently Asked Questions (FAQ s)

Transcription

1 Question GENERAL Why is Florida Blue implementing a Musculoskeletal Management Program focused on Interventional Pain Management procedures? Musculoskeletal Care Management Program Interventional Pain Management Frequently Asked Questions (FAQ s) Answer To improve quality and manage the utilization of nonemergent musculoskeletal care, including Interventional Pain Management (IPM) procedures for our members. NIA Magellan is the vendor manager for Florida Blue advanced imaging program and these new musculoskeletal modalities are an extension of that management program. Florida Blue providers will utilize the provider tools to request these studies as they do today for advanced imaging. Interventional Pain Procedures include: Why did Florida Blue select NIA Magellan? Which Florida Blue members will be covered under this relationship and what networks will be used? Spinal Epidural Injections Paravertebral Facet Joint Injections or Blocks Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis) An affiliate of Magellan Health Services, NIA Magellan was selected to partner with us because of its clinically driven program designed to effectively manage the quality, patient safety and ensure appropriate utilization of resources for Florida Blue membership. NIA Magellan manages non-emergent outpatient interventional pain procedures for BlueOptions SM (Network Blue) and BlueSelect plans that include the comparative effectiveness / prior authorization requirement, as well as, BlueCare, Blue HMO products effective July 1, MyBlue benefit plan will be added to this program as of January 1, NIA Magellan will manage non-emergent outpatient interventional pain management procedures through Florida Blue s contractual relationships. PROGRAM START DATE 1 Florida Blue Musculoskeletal Care Management Program

2 What is the implementation date for this Musculoskeletal Management Program? PRIOR AUTHORIZATION What Musculoskeletal Management services will require a provider to obtain a prior authorization? When is prior authorization required? Prior authorization is required for members currently undergoing treatment? Who do we expect to order Interventional Pain Management (IPM) procedures Are inpatient Interventional Pain Management (IPM) procedures included in this program? Does the setting of the service affect the required prior authorization? How does the ordering Implementation for this program was effective July 1, The expanded program including MyBlue benefit plan will be effective January 1, The following procedures require prior authorization through NIA Magellan: Spinal Epidural Injections Paravertebral Facet Joint Injections or Blocks Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis) Prior authorization is required for outpatient, nonemergent interventional pain procedures. Ordering providers must obtain prior-authorization of these procedures prior to the service being performed. Note: Only outpatient procedures are within the program scope. All interventional pain management procedures performed in the Emergency Room or as part of inpatient care do not require prior authorization. Yes, authorization is required for dates of service on or beyond January 1, 2016 even if the member is continuing treatment. Interventional pain procedures requiring medical necessity review are usually ordered by one of the following specialties. Anesthesiologists Neurologists Pain Specialist Orthopedic Spine Surgeon Neurosurgeon Other physicians with appropriate pain procedure training and certification Inpatient interventional pain management procedures are not included in this program. No, this medical necessity review and determination are for the authorization of the professional services. Any prior authorization requirements for the facility must still be obtained separately. Providers will be able to request prior authorization via 2 Florida Blue Musculoskeletal Care Management Program

3 provider obtain a prior authorization from NIA Magellan for an outpatient interventional pain management procedure? What information will NIA Magellan require in order to receive prior authorization? the NIA Magellan website or by calling the NIA Magellan toll-free number To expedite the process, please have the following information ready before logging on to the website or calling the NIA Magellan call center staff (*denotes required information): Interventional Pain Management Procedures: Name and office phone number of ordering physician* Member name and ID number* Requested procedure* Name of provider office or facility where the service will be performed* Anticipated date of service* Details justifying the pain procedure*: o Date of onset of pain or exacerbation o Physician exam findings and patient symptoms (including findings applicable to the requested services) o Clinical Diagnosis o Date and results of prior interventional pain management procedures. o Diagnostic imaging results, where available. Conservative treatment modalities completed, duration, and results (e.g., physical therapy, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and medication) Please be prepared to fax the following information, if requested: Clinical notes outlining onset of pain, conservative care modalities, outcomes and physical exam findings Date and results of prior interventional pain management procedures Effectiveness of prior procedures on reducing pain 3 Florida Blue Musculoskeletal Care Management Program

4 Can a provider request more than one procedure at a time for a member (i.e., a series of epidural injections)? What kind of response time can ordering providers expect for prior authorization? Diagnostic Imaging results Specialist reports/evaluation No. NIA Magellan requires prior authorization for each pain procedure being requested and will not authorize more than one procedure at a time. The best way to maximize the efficiency turnaround time of an authorization request on line through or through the toll-free number, (866) is to have knowledge of the case including: The patient s history and diagnosis Onset of pain Findings on physical examination Response and type of non-operative management the patient has undergone History of medical or surgical treatment Rationale for the procedure What will the NIA Magellan authorization number look like? If requesting an authorization through RadMD and the request pends, what happens next? Can RadMD be used to request retrospective or expedited authorization request? How long is the prior Generally, within 2 business days after receipt of request with full clinical documentation, a determination will be made. In certain cases, the review process can take longer if additional clinical information is required to make a determination. The NIA Magellan authorization number will consist of 8 or 9 alpha-numeric characters. In some cases, the ordering provider may instead receive an NIA Magellan tracking number (not the same as an authorization number) if the provider s authorization request is not approved at the time of initial contact. Providers will be able to use either number to track the status of their request online or through an Interactive Voice Response (IVR) telephone system. You will receive a tracking number and NIA Magellan will contact you to complete the process. No, those requests will need to be called into NIA Magellan s Call Center through the toll free number, for processing. The authorization number is valid for 90 days from the 4 Florida Blue Musculoskeletal Care Management Program

5 authorization number valid? If a provider obtains a prior authorization number does that guarantee payment? Does NIA Magellan allow retroauthorizations? What happens if I have a service scheduled for January 1, 2016? Can a provider verify an authorization number online? Will the NIA Magellan authorization number be displayed on the Florida Blue Web site? What if I disagree with NIA Magellan s determination? SCHEDULING PROCEDURES Will NIA Magellan make a final determination based on the Anticipated Date of Service? date of service. An authorization number is not a guarantee of payment. Authorizations are based on medical necessity and are contingent upon eligibility and benefits. Benefits may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. It is important that key physicians and office staff be educated on the prior authorization requirements. Claims for interventional pain management procedures, as outlined above, that have not been properly authorized will not be reimbursed. Physicians administering these procedures should not schedule or perform procedures without prior authorization. Retrospective review of completed procedures are evaluated for medical necessity and to determine whether there was an urgent or emergent situation that prohibited the provider from obtaining prior authorization for the service and to determine whether medical necessity guidelines were met. An authorization can be obtained for all pain management procedures for dates of service July 1, 2015 and beyond. NIA Magellan and Florida Blue will be working with the provider community on an ongoing basis to continue to educate providers that authorizations are required. Yes. Providers can check the status of member authorization quickly and easily by going to the website at No. In the event of a prior authorization or claims payment denial, providers may appeal the decision through Florida Blue. Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification. NIA Magellan does not guarantee final determination of the request by the anticipated date of service. The anticipated date of service (provided during request for authorization) is used to determine timing between 5 Florida Blue Musculoskeletal Care Management Program

6 procedures WHICH MEDICAL PROVIDERS ARE AFFECTED? Which medical providers are affected by the Musculoskeletal Management Program? Please be advised that NIA Magellan needs 2 business days after the receipt of clinical information to review and render a decision on a request. Please do not schedule or perform the procedure until you have an approved authorization. Specialized Providers who perform Interventional Pain Management (IPM) spine procedures in an outpatient setting. Florida Blue providers will need to request a prior authorization from NIA Magellan in order to bill the service. Providers who perform IPM procedures are generally located at: CLAIMS RELATED Where do providers send their claims for outpatient, nonemergent Musculoskeletal Management Program? How can providers check claims status? Who should a provider contact if they want to appeal a prior authorization or claims payment denial? MISCELLANEOUS How is medical necessity defined? Ambulatory Surgical Centers Hospital outpatient facilities Provider offices Florida Blue network providers should continue to send claims directly to Florida Blue. Providers are encouraged to use EDI claims submission Providers should continue to check claims status with Florida Blue at either : Providers are asked to please follow the appeal instructions given on their non-authorization letter or Explanation of Benefits (EOB) notification. Medical necessity means service that: Meets generally accepted standards of medical practice; be appropriate for the symptoms, consistent with diagnosis, and otherwise in accordance with sufficient evidence and professionally recognized standards; Be appropriate to the illness or injury for which it is performed as to type of service and expected 6 Florida Blue Musculoskeletal Care Management Program

7 How will referring/ordering providers know who NIA Magellan is? Will provider trainings be offered closer to the implementation date? Where can a provider find NIA Magellan s Guidelines for Clinical Use of Pain Management Procedures? What will the Member ID card look like? Will the ID card have both NIA Magellan and Florida Blue information on it? Or will there be two cards? CONTACT INFORMATION Who can a provider contact at NIA Magellan for more information? outcome; Be appropriate to the intensity of service and level of setting; Provide unique, essential, and appropriate information when used for diagnostic purposes; Be the lowest cost alternative that effectively addresses and treats the medical problem; and rendered for the treatment or diagnosis of an injury or illness; and Not furnished primarily for the convenience of the member, the attending physician, or other provider. Florida Blue will mail notification letters and educational materials to providers. Florida Blue and NIA Magellan are also conducting educational trainings for providers. Yes, NIA Magellan will conduct webinar training sessions prior to the implementation date. NIA Magellan s Interventional Pain Management Procedures Guidelines can be found on the website at or on They are presented in a PDF file format that can easily be printed for future reference. NIA Magellan s clinical guidelines have been developed from practice experiences, literature reviews, specialty criteria sets and empirical data. The Florida Blue Member ID card will not change and will not contain any NIA Magellan identifying information on it. Providers can contact Michele DeCaprio, Manager - Provider Relations at (800) ext Florida Blue Musculoskeletal Care Management Program